Thermoregulation

Body Temperature is a physiological variable that is precisely controlled by the body. Normal body
temperature represents the optimal thermal condition needed to support internal functions such as
enzymatic systems regulating cellular functions. (Thomas, K. 1994, p.15)

Thermoregulation is the process of maintaining thermal balance by losing heat to the environment at a rate
equal to heat production. (London, 2007)

Thermoregulation is controlled by the hypothalamus. (Thomas, K. 1994)

Thermal stimuli provide the Hypothalamus with

Temperature Information.

Hypothalamus interprets the information and

compares it to the temperature set point. If a
difference between the information and set
temperature is identified, the hypothalamus
send signals to the Pituitary and Sympathetic
Nervous System. The body will then respond by
modifying metabolic rate, vasomotor control,
muscular activity and sweating to produce heat
gain or heat loss.

(Thomas, K. 1994)

Development of the thermoregulation is an adaptive process. At birth thermal adaptation is critical to

transition and survival of the infant. “Thermoregulation is a critical physiologic function that is closely related
to the transition and survival of the infant. An understanding of transitional events and the physiological
adaptations that neonates must make is essential to helping the nurse/midwife provide an appropriate
environment and help infants maintain thermal stability.” (Thomas, K. 1994)

Intrauterine temperature is 37.9օC. Intrauterine preparation takes place prior to delivery by means of
catecholamine surge during labour which primes the infant to respond to temperature changes immediately
at birth. The infant does not overheat in-utero as the placenta produces prostaglandins which “contain” the
catecholamines. (Thomas, K. 1994)

Clamping of the umbilical cord, removes placental factors that suppresses Non-shivering thermogenesis
thus increasing brown adipose tissue metabolism. (Blackburn, 2013) As soon as the baby is born and
separated from the placenta the catecholamines stimulate non shivering thermogenesis. Unless immediate
attention is given to the infant at birth, the infant’s temperature will decrease by 4.5օC during the 1st minute
of birth. It is due to the increase of the metabolic rate and Non-shivering thermoregulation. This Non-
shivering thermoregenesis is producing ATP by the oxidation of fatty acids (brown fat) in the mitochondrias.
(Thomas, K. 1994)

“Infants born at term have a full range of thermoregulatory responses and if provided with appropriate
thermal insulation (swaddled) can maintain thermal stability over the environmental temperature range
within the home. By contrast infants born before 28 weeks gestation not only lose heat rapidly because of
very high rates of trans-epidermal water loss, immature skin and they also have little or no thermoregulatory
control. If they are to survive and flourish, they need external aids, like heated mattresses or must initially
be incubate like an egg and then the environment must be adjusted as they mature. It is an exacting task
which is central to modern intensive neonatal care.” (David Hull, 1988, p.971)
Principles of Heat Balance
  Heat is Conserved By:  Heat is Lost By:
 Peripheral Vasoconstriction  Vasodilatation
 Flexing extremities towards body  Stretched posture
 Lying very still
 Heat is Produced By:  Breathing faster
 Normal metabolic activity  Sweating: Preterm babies are unable
 Musclar activity to sweat until they reach 2 weeks old,
 Shivering which is the time that will take to the
 Metabolism of brown fat in the infant: sweat cells to mature.
Known as Non-Shivering
Thermogenesis.
(Thomas, K. 1994)

Modes of Heat Loss or Transfer

 Conduction
It is the transfer of heat between two solid objects that are in contact.

Heat Loss: When newborns come in contact with cool mattress, blanket, clothes, weighing scale and
X-Ray plate. Cold stethoscope in auscultating.
Heat Gain: If underlying surface is warmer than the baby. – increases body heat.
Prevention of Heat Loss: Measures to prevent conductive heat loss include warming the surfaces by
putting a blanket or pre-warming them before they come in contact with an infant, and providing
insulation between the infant and the solid surface.

 Radiation
It is the transfer of heat between solid surfaces that are not in contact with the body.

Heat Loss: Placing the incubators, cots and radiant warmers near external walls and windows.
Heat Gain: Unless a radiant heat source is present in a nursery, radiant temperature is typically lower
than air temperature.When an incubator is exposed to sunlight or phototherapy units can result in
overheating. Direct sunlight in the incubators, cots and radiant warmers.
Prevention of Heat Loss: The more layers the less heat the baby will lose by radiation. That is why they
have double layered incubators and some have heat shields. Using a radiant warmer transfers warmth
to the cooler infant.

 Convection
It is the transfer of heat between two solid surface (the infant) and either air or liquid surrounding the
baby.
Heat Loss: Heat loss from warm body surface to the cooler air currents. Loss is high if baby is naked
and the environment is cool.
Heat Gain: Insulating baby and maintaining ambient temperature.

Heat Loss and Heat Gain depends on:

 Temperature gradient (Temperature difference between baby’s surface and air):
> gradient between the infant’s skin temperature and the ambient temperature = > heat loss or gain
 Surface area exposed to air: > surface area to body mass = > loss by convection. Using plastic
wrap bags with VLBW infants from birth.
 Loss is high if baby is naked and the environment is cool. Insulating baby and raising ambient
temperature. Give warm oxygen because heat can be lost thru transfer or warmed inspired air yo
cold external air through exhalation.
 Speed of air movement: It is directly related to convective heat loss. The faster air flow velocity the
more convective heat loss will occur. Avoid baby’s exposure to drafts, ventilation systems and traffic
flow around the infant’s bed.
  Evaporation
It produces heat loss through the energy used in the conversion of water to its gaseous state. As water
evaporates from skin or breath, heat is lost. Each ml of water which evaporates removes 560 calories
of heat. Immature or damaged skin offers little resistance to diffusion of water.

Heat Loss: At birth, when baby is wet with amniotic fluid, therefore thorough drying is a critical
intervention.

 A way of preventing TEWL would be providing humidity to the environment or using plastic wrap
bags. When they have an increased in TEWL they cannot stay under a radiator heater, they need
humidity. The only exception is while resuscitating. TEWL results in loss of both heat and fluid,
under a radiant heater, the temperature of the baby is maintained because of radiant heat gain, but
the large fluid losses can be a serious problem. (Lyon, A. 2006)

(Thomas, K. 1994)

Sources of Heat Loss

 Internal Gradient: Transfer of heat from body core to external surface. This process relies greatly
on blood flow. It can be altered by vasomotor control process which is mediated by sympathetic
NS that change skin blood flow with the peripheral vasoconstriction to conserve heat or vasodilation
to close heat. It is greater in neonates because of thinner layer of subcutaneous fat and large body
surface area to body mass ratio.

 External Gradient: Transfer of heat from body surface to environment. This is also increased in
neonates because of large surface area exposed. The more surface area are exposed, the greater
the heat loss or heat gain is.

Transfer of heat is complex and depends on:

 Temperature of air
 Temperature of surrounding objects
 Speed of airflow
 Relative humidity

Impairment of Thermogenesis
 Hypoxia: Limited response of PaO2 at 6-7 kPa and abolished at 4kPa
 Neurological events: Intracranial haemorrhage, head injury which involves the hypothalamus,
cerebral malfunctions such as NTDs
 Hypoglycemia
 Drugs: Neonatal Narcan which is used to be part of the resus trolley, now it cannot be used unless
there is evidence that it is totally needed.
 Lipid depletion in the diet

Preterm Infant
Their heat losses are greater in comparison to the term baby because:
 Thermoregulation is immature
 Non shivering
 Will metabolise brown adipose tissue-
depleting valuable energy stores
 Evaporative heat loss exceeds ability for
heat production
 They have thinner skin (2-3 cells thick)
with less subcutaneous fat
 Has less keratin, therefore leaks water
TEWL
 No sweat glands, no sweat response.
Preterm babies are unable to sweat until
they reach 2 weeks old, which is the time
that will take to the sweat cells to mature.
 Blood vessels just below skin surface
 Posture
 Larger body surface area to weight ratio
 Weight 500g  Produce less body heat per unit surface
SA: 1.1 cm2/g area
Weight 3,500g
SA: 0.6 cm2/g

(Thomas, K. 1994)

Transepidermal Water Loss

It is high in the immature baby. At 26 weeks gestation, on the first day of life, the baby can lose over
50kcal/kg via evaporation, compared with less than 5kcal/kg in the term infant. It depends on the ambient
water vapour pessue, irrespective of how the baby has been nursed. (Lyon, A. 2006)

Trans Epidermal Water Loss (TEWL) insensible loss

from the skin is correlated with Gestational Age and the
degree of keratinization. Mature keratin is relatively water
impermeable, so premature infants (immature keratin)
have increased evaporative losses as body water
diffuses across the permeable skin barrier and
evaporates. Keratinization increases over the first 3 to 4
weeks of postnatal life and contributes to a reduction in
evaporative loss. The more premature the infant, the
greater the TEWL.
Body water in preterm neonates is approximately 90% of
total body weight due to increased extracellular fluid and
proportionally less body fat.

Relative Humidity
The rationale for providing humidity is bases in knowledge about thermal regulation and decreased
evaporative heat losses. In a dry cool environment, the rate of evaporative heat exchange between the skin
surface and the surrounding incubator air may be so high that the evaporative losses alone may exceed
the infant’s total metabolic heat production, thus humidity is needed. It has been found in several
investigations that basal evaporative water loss can be consistently reduced by increasing the ambient
temperature and adding humidity. When infants are nursed in high humidity, fluid requirements and
electrolyte imbalance are reduced. It decreases evaporative heat loss, however, it has to be kept at a very
high (80%) and steady level for at least the first few weeks of life before weaning to 50% and gradually to
room temperature by 4 weeks of age. The newest incubators today have a more active dynamic
humidification system that allows better management of the ambient humidity. (Fidler, H. 2011)

Water content of air expressed as a

percentage of the maximum possible water
content and air temperature

Room air 20օC = 50%

NICU 30օC = 30%
Dry incubator 27օC = 25%

Our hospital policy considers starting

humidity for at least 1 week in babies less
than 28 weeks and less than 1kg. From week
2 it can be weaned down.

Although there are any benefits of using

humidity, one risk is a delay in the maturation
of the skin barrier. This immature skin may allow introduction of bacteria through the skin ad may explain
why there is a higher incidence of infection in infants cared for with higher humidity levels. Studies suggest
that humidity is still beneficial, but lower levels may decrease the risks involved in using humidity. If higher
humidity is used, it is imperative to wean the level down towards 60% as soon as infant can tolerate the
lower levels. (Knobel, R. 2014)

Thermal Stress
Heat Stress: Usually consequence of the improper use of heating devices.
Cold Stress: Is the most common and can lead to an increment in mortality and decrement the growth in
preterm babies. It results from failure to understand/appreciate how a baby loses heat and how to reduce
these losses. It can cause (Kenner&Lott, 2014)

Response to Cold Stress

Regulation of body temperature depends on vasomotor and sudomotor activity, change in motor tone and
modification of heat production. Rapid response to an increase in environmental temperature causes
vasodilation which increases blood flow to the periphery, dissipating heat and producing cooling.
Conversely vasoconstriction reduces blood flow to reduce heat loss from the skin’s surface. (manifested by
infant being pale and having mottled skin) Both processes require adaptation of cardiovascular dynamics
to maintain systemic perfusion pressure. (Thomas, K. 1994)

If first line defences are inadequate to conserve heat, heat production is altered resulting in requiring
newborn to use compensatory mechanisms:

Summary: When a neonate has a cold stress, enegy is shifted from maintaining normal function of vital
organs to thermogenesis for survival. (Kenner&Lott, 2014)

Increased oxygen
consumption. Body
Muscular activity compensates by
increasing respiratory
rate, however, oxygen
needed is greater than
Increased glucose the amount available,
requirement. thus leading to
Glycogen stores hypoxia.
will then be As a normal
compensatory,
converted to mechanism, anaerobic
glucose. metabolism and
As a result, production of lactic
Glycogen stores acid will occur leading
to in pH, thus
will be depleted decrease, metabolic
and hypoglycemia acidosis.
and weight loss
will occur. Resulting to
Pulmonary blood
vessels will constrict,
further contributing to
hypoxia which will then
lead to respiratory
distress.
Another mechanism of te body in oping to cold stress is the NST.
Shivering is poorly developed in infants, non-shivering thermogenesis, which utilizes brown fat
tissue metabolism is the primary heat production mechanism in neonate. It generated more
energy than any other tissues in the body. Brown fat metabolism is activated when SNS release
norepinephrine. It involves breakdown of triglycerides to glycerol and non-esterified fatty acids,
thus contributing to the decrease in pH. Elevated fatty acids in the blood may also compete with
the albumin binding sites displacing bilirubin then increasing the risk of jaundice. Brown fat tissue
are reduced in the preterm infant and minimal in the VLBW. Brown adipose tissue is located
primarily in the midscapular, nape, axillary, mediastinal regions, esophagus, heart, kidneys and
adrenal glands.
 (Blackburn, 2013)

Neutral Thermal Environment

To prevent heat and cold stress nurse the baby in a neutral thermal environment, which allows the baby to
use the least amount of oxygen to maintain a normal temperature. (Thomas, K. 1994)

Thermal Environment and Body Temperature

Two interrelated concepts are central to thermal care:

Set point: Defines controlled temperature in the thermoregulatory system. Normal body temperature is the
clinical manifestation of set point.
Neutral Thermal Zone: Has traditionally been defined as a range of environmental temperatures within
which the metabolic rate is minimal and thermoregulation is achieved by nonevaporative means. Within this
range, the infant is thermal equilibrium with the environment. (Thomas, K. 1994)

Management of Hypothermia
Temperature <36.5 օC

Types Mild Moderate Severe

Temperature 36.0օC - 36.4օC 32.0օC - 35.9օC <32.0օC
Management  Skin to skin contact  Heated Mattress  Heated Mattress
in a Warm room  Radiant warmer  Radiant warmer
32.0օC - 34.0օC.  Pre-heated  Incubator
(placing infant with Incubator set at  +
a diaper only, 35.0օC - 35.9օC  Fast rewarming
directly on the  Continue feeding to over a few hours is
mother’s bare chest provide calories preferable tha slow
and covering them and fluid to prevent rewarming for
both with the hypoglycemia several days
blanket.
 Continue feeding to  Continue feeding to
provide calories provide calories
and fluid to prevent and fluid to prevent
hypoglycemia hypoglycemia
(Cinar & Flitz, 2006)

Management of Hypothermia
Temperature >37.5 օC
 Although less common, can occur just as easily as hypothermia and as equally as dangerous.
 Assessment of heating devices and methods used is necessary to correct any environmental
factors present.
 It is paramount to differentiate hyperthermia from fever - which is a raised body temperature in
response to infection or inflammation. Infection must always be considered significantly.

Cause  Wrappig the baby in too many layers of clothes

 Leaving the baby in direct sunlight or
 Putting the baby too close to a heater
Management  Putting the neonate away from the source of heat
 Undress partially or fully
 Continue feeding the baby to replace fluids.
(Cinar & Flitz, 2006)